[HSF] Coronary Case
Nasser F. Abou'Seada
nfaabouseada at gmail.com
Thu Feb 1 00:07:52 EST 2007
Dear Ani
I do see your point of view, though I may argue against some pints in it.
Yet the logic in your argument is evident and well organized. Mind You, I
never meant to deny any patient what he / she would seek for him / herself.
All I was stressing at is to attain the optimal conditions before embarking
on the second step, interference I mean. I do agree with you that a patient
wish should always be respected, within the frame of standard code of
practice. I am sure we both agree to that, as I do remember the logic that
we were taught in the same school of training, preparing for the final RCS
exams ... we both share the same school of logical thinking, albeit making
different arguments. I do still remember Marc E. Lambert, Consultant
vascular Surgeon my first mentor in England, teaching me the attitude for
answers "if you can argue for your answer and substantiate it, you can pass
with it". I am sure you agree with me that there is nothing dogmatic in
life, neither in surgery, and that everything "depends on the determinants
of its variables" ....
Still, I can assure you that I would NOT let down a patient, would certainly
advise to the best of my knowledge and experience, about the best conditions
to be taken before a certain procedure. I am sure you are aware of the
dictum in vascular surgery "not to operate on any female should she have
been on the pill in the previous (-) months before surgery" .... the number
differs as per surgeon's conviction .. .... certainly NOT letting down a
patient .... put surely optimizing the conditions before attempting a
serious interference.
I'd think the Case for DeBakey was a function of the ability of the
operating team and Skillful resources available rather than a personal
opinion of a certain surgeon, meaning that the decision was dependant on the
PROFESSIONAL personal judgment of the expected results weighed against the
risks involved. Certainly a landmark pointing to the school that he has
initiated in the history of Aortic Surgery.
Thank you indeed for your logical input and objective comments. that really
was very enriching to the discussion and display of different opinions and
arguments.
Yours
NFA
> From: Ani Anyanwu
> NFA
> If doctors had a central logic or science to base their decisions then
that is fine for us
> to to be societies gate-keeper. Otherwise, what we are left with is what
we call a
> postcode lottery in the UK. The treatment you get depends on where you go.
If you
> go to Hal or Yourself you get turned down if you come to me or Chand or
Salerno you
> get surgery etc. That is why we cannot gate keep for society because we
all see things
> differently - some smokers will get surgery others wont. Some might die of
an MI
> because they were turned down, others might die of respiratory failure
because they
> were not - you can argue it either way.
>
> On the other hand if the government through the medical purchasers or
regulatory
> bodies proscribes CABG will not be performed unless urine nicotine is
absent for 3
> consecutive weeks, then we will all do that and it can work.
>
> Transplantation is unique because the resource is finite (unlike other
resources though
> limited often not visibly finite). So with 100 people competing for one
donor and the
> opportunity cost of using the heart in one person is the loss of a chance
to life in
> another, society asks that we allocated these organs in a rational and
judicious way.
> You are right we should do the same with all healthcare resources but the
problem
> arises when patients can (and do) buy (or think they buy) their own health
care. In
> the same way you could walk in a shop and buy a mercedes or a rickety 30
yr old
> jallopy, health economists argue that you should also be able to buy your
own
> healthcare. So if a smoker chooses to buy a CABG then all he needs is to
find a
> provider willing to sell it. To deny him would be do deny him the right to
choice in a
> free market. After all was that not how DeBakey supposedly got his
surgery? How
> many on here would have agreed to offer him surgery - I bet none or maybe
one or
> two - but his family and doctors looked around till they found a willing
surgeon; and
> he is supposedly doing well (from the recent thread) despite the
conventional wisdom.
>
> Ani
> ----- Original Message -----
> From: Nasser F. Abou'Seada<mailto:nfaabouseada at gmail.com>
> To: OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com>
> Sent: Wednesday, January 31, 2007 1:06 AM
> Subject: RE: [HSF] Coronary Case
>
>
> > I encourage patients to stop smoking but apart from transplantation,
where
> ethical
> > and (donor) resource issues force rationing, I would generally not
deny a
> patient
> > therapy for smoking alone , except where there is a strong medical
basis
> (usually 1 or
> > 5 above, but I would argue such instances are rare). It is up to
society,
> and not I, to
> > decide who deserves health care dollars and who doesn't and what
levels of
> relative
> > benefit (and risk) justify such expenditures.
>
> Such an argument seems a little bit twisted. Isn't rationing resources
for a
> complex complicated highly technical demanding procedure like a cardiac
> revascularization procedure, an ethical issue in itself ? ...
> Do you consider providing and establishing the PROPER preoperative
milieu -
> in terms of patient's physiology and pathophysiology- a denial of
treatment
> ???? ... I trust we all have certainly been exposed to that logic in
> preliminary basic surgical training .... at least I can confirm that as
of
> my training in UK ... !!!
>
> Is not being certified as a surgeon with a respectable credentialed
> training, by a society, an admission of the society, to those
credentialed
> in their prospective field of expertise, to delegate the responsibility
of
> decision making of who deserves the health care dollars ???? .....
giving
> that responsibility up, would just down rank our surgical "institution"
to
> the rank of a paid expert manual worker doing the "cutting" for payment
....
> !!!!
>
> Who else should the society, in first place, delegate that
responsibility to
> ????? .... to decide for " what levels of relative > benefit (and risk)
> justify such expenditures." ?????
> the concept of course differs from looking at "it" from within "context"
..
> or else as an outsider to the "system" ....!!!!
>
> your thoughts and discussions are greatly enriching and appreciated
>
> NFA
>
> > From: Ani Anyanwu
> > I suspect this has either been tried before (and did not work) or
tried
> before (and
> > failed).
> >
> > Are you turning her down because
> > 1) you believe the smoking is directly the cause of the symptoms (and
the
> only
> > effective treatment is cessation) or
> > 2) you believe the smoking is directly the cause of the symptoms (and
> while other
> > therapy may be helpful that you will not offer them because there is
what
> you believe
> > a simpler way to treat it)
> > 3) smoking reduces the chances of success of therapy
> > 4) smoking is detrimental to the longevity of the procedure or
disease.
> > 5) smoking virtually eliminates chances of immediate success of
therapy
> >
> > Unless it is the first, I would argue that serious ethical questions
> exist. What would
> > you write in the charts and what would you tell your (Florida)
attorneys
> if she has an
> > infarct tomorrow?
> >
> > Smoking is an addiction and as much a disease as is the coronary
disease,
> diabetes,
> > obesity, hypertension, renal failure etc - in the same way some cases
of
> HTN or DM
> > are very difficult or impossible to control, some cases of smoking are
> impossible to
> > control.
> >
> > I encourage patients to stop smoking but apart from transplantation,
where
> ethical
> > and (donor) resource issues force rationing, I would generally not
deny a
> patient
> > therapy for smoking alone , except where there is a strong medical
basis
> (usually 1 or
> > 5 above, but I would argue such instances are rare). It is up to
society,
> and not I, to
> > decide who deserves health care dollars and who doesn't and what
levels of
> relative
> > benefit (and risk) justify such expenditures.
> >
> > Ani
> > ----- Original Message -----
> > From:
> hgrmd at aol.com<mailto:hgrmd at aol.com<mailto:hgrmd at aol.com<mailto:hgrmd at aol
> .com>>
> > To: OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-
> L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-
> L at lists.hsforum.com>>
> > Sent: Tuesday, January 30, 2007 10:23 AM
> > Subject: Re: [HSF] Coronary Case
> >
> >
> > Ani,
> > Before you wade into a possibly elective, ineffective, CABG
nightmare,
> I would
> > insist that the lady absolutely undergo a trial of smoking cessation.
If
> necessary, this
> > should be confirmed by urine screening for nicotine metabolites. It
could
> be that
> > heavy smoking is producing disabling spasm. I am usually not that
tough
> on patients
> > about smoking (though I should be), but this is possibly the
exception.
> Tough case.
> > Hal
> >
> >
> > -----Original Message-----
> > From:
> prasannasimha at gmail.com<mailto:prasannasimha at gmail.com<mailto:prasannasimh
> a at gmail.com<mailto:prasannasimha at gmail.com>>
> > To: OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-
> L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-
> L at lists.hsforum.com>>
> > Sent: Tue, 30 Jan 2007 6:42 AM
> > Subject: Re: [HSF] Coronary Case
> >
> >
> > Could you dig out the IVUS report ??
> >
> > I agree that angiography could underestimate the disease but you
also
> > say there is no inducible Ischemia on Thallium (that doesn't go hand
in
> > hand)
> > Assuming that the lesion is the cause of Ischemia, I would have to
graft
> > LAD with all the diagonals and probably the RCA. It still seems like
we
> > are being "tricked" into saying graft. That makes me suspicious.
> > I am still curious of the possibility of the open highway and
blocked
> > side roads.If that is really the case what you need to do then is
stent
> > endartrectomy, open up side branches and place a large patch over
all of
> > this and place an IMA or distal IMA and grafts (sequentialize the
IMA to
> > all the involved diagonals)
> > No arterial graft on the RCA would use an SVG.
> > Could probably consider partial cardiac denervation (though I am not
> > sure if if the blessed thing works).
> >
> > 12 caths over 36 months still is a bit too much - one cath every 3
> > months on the average for 3 years still is a pincushion situation !!
> > I strongly suspect that she will not have good relief of symptoms
post
> > surgery unless there is some objective evidence of Ischemia. Is the
gun
> > at our heads because she has become a pincushion and someone is
trying
> > to finally dump a problem on you ??
> > Prasanna
> > Ani Anyanwu wrote:
> > > Thanks for responses.
> > >
> > > I specifically had said to assume you will operate on the patient
just
> to
> > > divert the discussion away from indications of surgery but as I
> expected
> > > that is where everyone decides to focus!
> > >
> > > The 12 caths were over 3 years not 18 months. She has been
> investigated for
> > > non-cardiac chest pain but it keeps coming back to the heart.
Clearly
> there
> > > is a suspicion that something is not right with the stent or that
some
> > > disease is being missed, which is why they keep re-imaging it. Had
> IVUS
> > > after second stent so they were clearly concerned about placement.
> Symptoms
> > > are almost certainly anginal and are relieved by nitrates (I know
so
> can
> > > esophageal pain but that is rarely triggered by exertion). She did
> have an
> > > objective coronary lesion and ECG changes on first presentation
and
> also a
> > > thallium that showed apical ischemia so the patient definitely has
had
> > > symptomatic coronary disease. Has been worked up by cardiologists
in
> two
> > > separate cities both of which come to same conclusion (coronary
pain)
> and
> > > she has been managed on medical therapy. She shouldn't be smoking
but
> does
> > > (again that's life - actually says she 'stopped' a month ago).
> > >
> > > Indication for CABG is intractable angina with angiographic (LAD)
> disease.
> > > Angiography can and does underestimate luminal narrowing so the
> presumption
> > > has to be that 40% ISR within a 5 cm of stent counts for more than
> that (in
> > > the absence of alternative explanations). The RCA spasm can be
> debated. In
> > > my view I suspect there may be a real lesion; I do not know if she
had
> pain
> > > during the cath (I suspect many of them do if you watch what
happens
> in the
> > > lab). She also has (minor) disease in her ramus. I am not sure if
> stent has
> > > pinched diagonals - will go back and have a look. I have not said
I
> would
> > > graft any vessel - I was just presenting options of what is
surgically
> > > graftable (the six vessels I listed) not what should be grafted
(which
> some
> > > would say is none).
> > >
> > > Still waiting for operative suggestions - what if you had a gun to
> your head
> > > in the OR, what would you do for this lady!
> > >
> > > Ani
> > > ----- Original Message -----
> > > From:
> >
> prasannasimha<mailto:prasannasimha at gmail.com<mailto:prasannasimha at gmail.co
> <mailto:prasannasimha at gmail.com<mailto:prasannasimha at gmail.co>
> > m>>
> > > To:
OpenHeart-L at lists.hsforum.com<mailto:OpenHeart<mailto:OpenHeart-
> L at lists.hsforum.com<mailto:OpenHeart>-
> > L at lists.hsforum.com<mailto:OpenHeart-
>
L at lists.hsforum.com<mailto:OpenHeart<mailto:L at lists.hsforum.com<mailto:OpenH
e
> art-L at lists.hsforum.com<mailto:OpenHeart>-
> > L at lists.hsforum.com<mailto:L at lists.hsforum.com>>>
> > > Sent: Tuesday, January 30, 2007 3:45 AM
> > > Subject: Re: [HSF] Coronary Case
> > >
> > >
> > > I still remember an elegant expose given by Unique pharma on
cause
> of
> > > chest pain !!
> > > I would also check for an esophageal motility disorder (cork
screw
> > > esophagus) and gall bladder dysfunction which can mimic angina
in
> all
> > > aspects including relief with nitroglycerine. Especially in a
> smoker.
> > > Prasanna
> > >
> > > Tohru Asai wrote:
> > > > Dear Ani
> > > >
> > > > What is the indication for CABG? I don't think bypass will
help
> this
> > > > patient. Coronary spasm may complicate the procedure.
> > > >
> > > > What is pulmonary status? I experienced a case with giant
bulla,
> causing
> > > > angina-like symptom. It is rare but was writen in Shields'
> textbook of
> > > > General Thoracic Surgery.
>
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